cerebrospinal fluid rhinorrhoea & its...
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Saturday, September 20, 2008
CEREBROSPINAL FLUID RHINORRHOEA & ITS MANAGEMENT
Presented by : Dr Sachin A Borkar
Department of Neurosurgery,AIIMS, New Delhi
Saturday, September 20, 2008
Introduction
CSF rhinorrhoea refers to a fistula between the subarachnoid space and the nasopharynx – this may be direct via the anterior cranial fossa and PNS orindirect from the middle or posterior fossa via the eustachian tube with an intact tympanic membrane
Saturday, September 20, 2008
Historical Perspective First described by Galen, 200 B.C.Saintclair Thompson reported the first series of patients with spontaneous leakage in 1889The first well-succeeded surgical approach was attributed to Dandy in 1926, when he sutured the fascia lata over dural defect, on back of the posterior wall of the frontal sinus, by intracranial routeIn 1964, Vrabec and Hallberg described endonasal approach to repair a CSF leak in the cribriform lamina
Saturday, September 20, 2008
Introduction
MCF•Sphenoid sinus- lat
extension•Petrous bone to
middle ear
ACF•Cribriform plate
•Frontal sinus•Sphenoid sinus
PCF•Petrous bone to
middle ear
CSF rhinorrhoea
Saturday, September 20, 2008
Causes of CSF rhinorrhoea
CSF Rhinorrhoea
Traumatic Spontaneous
Surgical Non-surgical
Acute Delayed
High Pressure Low pressure
Saturday, September 20, 2008
Causes of CSF rhinorrhoeaTraumatic –
Acute / Early – within 1 weekDelayed – month/year laterNon-surgical-
Blunt trauma – Basilar skull fractureProjectile trauma
Surgical / Iatrogenic / Post-operative leaks-CraniotomyParanasal sinus surgerySkull base tumour ablationTranssphenoidal surgery
Saturday, September 20, 2008
Causes of CSF rhinorrhoea
Spontaneous / Non-traumatic –High-Pressure Flow -
Intracranial tumoursHydrocephalus
Low-Pressure Flow –Bony erosion, Osteomyelitis, OsteonecrosisSellar atrophyOlfactory atrophy / Focal cerebral atrophyCongenital defects of skull basePneumatized boneIdiopathic
Saturday, September 20, 2008
Traumatic CSF rhinorrhoea
MC cause of CSF leak is head trauma, particularly, basilar skull fracture
CSF leaks occur in approximately 3% of all head injuries & 12-30% o basilar skull #, depending upon the accelerative forces
Typically begin within 48 hours, and 95% will manifest within 3 months of injury
Saturday, September 20, 2008
Traumatic CSF rhinorrhoea
Roofs of ethmoid & the cribriform plate MC site-
Thinnest area of the ethmoid roof
Dura tightly adherent to bone in this area
Natural dehiscence created by Anterior Ethmoidal Artery in the region of lateral cribriform plate
Prolongation of the subarachnoid space along the olfactory nerve rootlets with subsequent rupture
Saturday, September 20, 2008
Traumatic CSF rhinorrhoeaDelayed Post-traumatic CSF Leak –
Lysis of clot in the area of fractureResolution of soft tissue edemaLoss of vascularity with necrosis of soft tissue around the woundDelayed increase in ICP after trauma
Saturday, September 20, 2008
Post-operative CSF rhinorrhoea
Iatrogenic/Post-operative CSF rhinorrhoea Trans-sphenoidal hypophysectomy, Ethmoidectomy, Anterior skull base tumour ablation e.g. olfactory groove meningioma
May be compounded by altered post-operative CSF flow characteristics or unrecognized/untreated hydrocephalus
Less likely to resolve spontaneously compared to nonsurgical traumatic cases as the dural and bony defect is large
Saturday, September 20, 2008
Spontaneous CSF rhinorrhoea
Leaks that are explained neither by trauma nor by any other cause
Tumours and raised ICP are highly correlated with spontaneous CSF leak
Pituitary tumours are the most common neoplastic cause of spontaneous CSF leak, due to sellar erosion
Saturday, September 20, 2008
Complications of Untreated CSF fistula
Meningitis – 3-11 % risk within first three weeks after trauma, overall risk 25%, with 10 % mortality, more with delayed CSF fistula, MC organism isolated is PneumococcusPneumocephalus – 20-30 %, including life-threatening tension pneumocephalus→ indicates open communication with significant risk of meningitis and encephalitisCerebral Abscess EncephalitisHeadache
Saturday, September 20, 2008
Diagnostic Approach
CSF rhinorrhoea
Confirming thatthe leaking fluid
is CSFDelineating the site of
CSF fistula
Defining the mechanism of production of CSF fistula
Saturday, September 20, 2008
Clinical evidence of CSF LeakUnilateral clear watery nasal discharge with a salty tasteDripping in the back of throatHeadache –
High pressure – build up over time & relieved by sudden discharge of fluidLow pressure – postural headache relieved by reclining
Reservoir sign- Large volume of fluid flowing out of the nose during a change in head position – indicates that a CSF-filled sinus has drained at onceRecurrent attacks of headache, fever and meningitis in a patientwith history of head trauma→ Look for CSF fistulaProvocative Tests – Occult CSF leak can be made manifest with the aid of – Valsalva maneuver
- Jugular venous compression- Flexing the neck in sitting position
Saturday, September 20, 2008
Clinical evidence of CSF LeakTarget sign/Halo sign : Pseudochromatographic pattern produced by differential diffusion of CSF admixed with blood or other serosanguinous fluid on filter paper – CSF produces a “Bull’s eye pattern “with blood in the centerGlucose : CSF - >= 50-66 % serum concn.
Nasal secretion <= 10 mg%Chloride concentration > 110 mEq/L → Most likely CSF
Qualitative spot test – Dextrostix - Not definitive- Negative test excludes the presence of
CSF
Saturday, September 20, 2008
Clinical evidence of CSF Leak
Immunological methods –Differentiates between proteins in CSF & those in nasopharyngeal secretions
β2- transferrin –Highly accurate way of determining presence of CSF; present only in CSF, aqueous humor & perilymph
Most sensitive & specific test available to date
β -trace protein ( Prostaglandin β synthase)
Saturday, September 20, 2008
Clinical evidence of CSF Leak
Other contributory evidence-Unilateral/bilateral anosmia - defect or leak in the region of cribriform plate
Imbalance, dizziness, hearing loss, VII nv.dysfunction- temporal bone fracture
Optic nerve lesion – injury in the region of tuberculum sellae, sphenoid sinus and the posterior ethmoids
Saturday, September 20, 2008
NeuroimagingPlain X ray Skull
Basilar skull fractureAir-fluid level in the PNS
CT with bone windowsFine-cut(3mm)CT in both coronal & axial planes with 3D reconstruction
Sphenoid, ethmoid & cribriform plate # best identified on coronal imagesCan locate the fistula in more than 50 % cases
CT cisternography
Saturday, September 20, 2008
Neuroimaging- CT cisternography
Water soluble contrast agents- iohexol, metrizamide
Procedure-Baseline CT head done
Contrast injected in subarachnoid space via a C1-C2 cisternal pucture, prone pt placed in Trendelenberg position for 4 min
Table is then made neutral, pt’s head extended slightly,and another CT head performed
Active leaks-76-100%, Inactive leaks-60%
Saturday, September 20, 2008
NeuroimagingMRI
MRI with heavily T2W images & CISS sequences
( MR Cisternography) 3D evaluation is done using the CISS technique with 0.7-mm thickness in the sagittal and coronal planes.
Highly accurate in localising the site and extent of CSF fistula
Non-invasive, No contrast required
Direct nasal endoscopy-visualizaton of fistula from ethmoid, sphenoid and cribriform plate
Saturday, September 20, 2008
Neuroimaging-Radionuclide cisternography
Also called as ‘Nasal Pledget Staining’Useful for intermittent CSF fistulaTc99 labelled albumin, In111 labelled DTPAPlacement of cotton-pledgets along areas thought to be harbouring a fistulaSlow or intermittent leaks detected by leaving the pledgets in place for 6-48 hrsRI ( Radioactivity Index) ratio=RI pledget/ RI 1ml of patients blood
RI<0.3-Normal, >1.5-CSF leak
Saturday, September 20, 2008
Interpretation of Radionuclide cisternography(Nasal Pledget Staining)
Location of stain Probable site of fistula
Anterior nasal Cribriform plate or anterior ethmoidal roof
Posterior nasal or sphenoethmoidal
Posterior ethmoid or sphenoid sinus
Middle meatus Frontal sinus
Below posterior end of inferior turbinate
Eustachian tube
( middle fossa )
Saturday, September 20, 2008
Neuroimaging- Tracer study
Useful for intraoperative localization of CSF fistula
Principle- Ability to retrieve extracranially a tracer substance injected into the CSF
Fluoroscein, Indigo-carmine
Saturday, September 20, 2008
Management of Traumatic CSF rhinorrhoea
Most traumatic CSF leaks stop on their own-35 % leaks stopped within 24 hours
68 % within 48 hours
85 % within 1 week
Conservative Management
(Mincy JE: Post-traumatic CSF fistula of the frontal fossa. J Trauma 6:618,1966.)
Saturday, September 20, 2008
Conservative management
Position – elevate head 30-450 for cranial leaksAvoid sneezing, coughing, strainingMonitor carefully for neurological deterioration- meningitis or pneumocephalus?Antibiotics– for prevention of meningitisPharmacological adjuvants – Diamox, Frusemide
Saturday, September 20, 2008
Role of Lumbar CSF drainage
Rationale – Granulation tissue can seal the fistula provided that the leak has stopped
Indicated if positioning and diamox alone does not significantly decrease CSF leak within 24 hours
CSF drainage to be continued for 3 – 5 days after stoppage of leak to allow healing
Saturday, September 20, 2008
Role of Lumbar CSF drainage
Complications –Over drainage of CSF – pneumocephalus, intracranial haemorrhage
High CSF protein concentration - Blockage
Meningitis – incidence can be reduced by tunneling the external catheter and by prophylactic antibiotics
Broken catheter tip
Dural-cutaneous fistula -
Stitch
Epidural blood patch
Saturday, September 20, 2008
Indications of Surgical Intervention
Recurrent attacks of meningitis with continuing leak despite conservative managementPatients with enlarging pneumocephalus ( > 2 cc persistent intracranial air - significant) despite conservative treatmentAcute traumatic or post-operative leaks that recur or persist after 10-13 days of conservative management including Lumbar CSF drainageProven intermittent or delayed leaksHigh pressure leaks with hydrocephalus
Saturday, September 20, 2008
Indications of Surgical Intervention
Radiological appearances that indicate a low probability of natural dural repair-
Erosion, destruction or severe comminution of skull base or sinuses
Intracranial spikes of bone
Soft tissue between the bony edges
Leaks associated with congenital dysplasia of brain, skull base; particularly after a bout of meningitis
Saturday, September 20, 2008
Indications of SurgicalIntervention
Leaks caused by high-energy missile wounds
High volume leaks through sella and petrous bone are particularly resistant to conservative management
Saturday, September 20, 2008
General Principles
Treat meningitis and rule out hydrocephalus before embarking on any surgical procedureCareful identification of the site and extent of the dural defectDissection of the bony and dural defectDirect dural repair if possibleClosure using a graft( ± glue), if direct dural repair is not possible
Saturday, September 20, 2008
Surgical management
Surgical management of CSF rhinorrhoea
Intracranial Extracranial
Intradural Extradural Open Endoscopic
Intradural -extradural
Saturday, September 20, 2008
Intracranial approachesPosition- Supine with head slightly extended to allow frontal lobes to fall backwardsHead-end of table elevated by 150 to facilitate venous drainageBicoronal skin flapElevate the pericranium as a separate layer for subsequent anterior cranial fossa repairCare taken to preserve supraorbital nerves-conversion of foramen into a groove
Saturday, September 20, 2008
Intracranial approaches
Very important to fashion the bone flap very low to clearly visualize the floor of anterior cranial fossa & the site of leak
Dealing the frontal sinus
Extradural or Intradural
Saturday, September 20, 2008
Intracranial , extraduralexploration - Limitations
Dural tears virtually inevitable in the course of dissection, makes identification of “original” traumatic CSF fistula more difficult
Areas of cerebral tissue herniation into bony defects cannot be easily visualized
Permanent dural repair is not reliably achieved
Saturday, September 20, 2008
Intracranial , intradural exploration
Excellent exposure of the entire anterior cranial fossa way back to the lateral aspects of sphenoid wings and posteriorly upto the plannum & anterior clinoid processesDura should be opened far anteriorly, which may require anterior third of SSS to be ligated and cutFalx must also be cut to provide full exposureIdentification –
Areas of parenchymal brain contusionBrain may be adherent to or herniated through the defectIdentification with the help of positive pressure ventilation
Saturday, September 20, 2008
Intracranial , intradural exploration - Indications
Once located, the fistula is to be packed with a plug of fat – to be reinforced with a dural patch graft from autologous pericranium, temporalis fascia or fascia lata + biological glueIf a discrete fistula cannot be identified-
Cover the entire anterior cranial fossa floor with a large pericranial graft all the way upto plannum sphenoidale & cover both cribriform plates + biological glue
The use of fibrin glue have improved the success of operative closure and is strongly recommended.
Saturday, September 20, 2008
Management of Petrous # with CSF otorrhoea/otorhinorrhoea
Longitudinal # rarely need repairSubtemporal craniotomy and extradural approachIf mastoid air cells are opened, they are plugged with bone waxRepair of the defect with fascia and glue
Saturday, September 20, 2008
CSF shunting( VP / TP shunt ) Hydrocephalus must be excluded first in any case of CSF rhinorrhoea, which fails to respond to conservative managementCarried out in conjunction with anatomic repair of a fistula or resection of a mass lesion in the face of hydrocephalusSmall leaks that cannot be identified
Saturday, September 20, 2008
Extracranial, extradural approach (Open / Endoscopic)
Considered for-Sphenoid
Parasellar
Posterior wall of frontal sinus
Cribriform / ethmoid
Petrous
CSF fistula
Unsuitable for-Bilateral fistula
Where site of CSF leak is uncertain
Where intracranial debridement of brain and brain is necessary
Saturday, September 20, 2008
Extracranial, extradural approach (Open / Endoscopic)
Discrete, clearly defined normal pressure leaks from anterior cranial fossa including cribriform plate and adjacent ethmoidPost-operative CSF leak after Transsphenoidal surgery, not controlled by conservative managementFractures that abut on an air sinus, particularly when the bony defect is limited to the cranial wall of the sinus
Saturday, September 20, 2008
Extracranial, extradural approach (Open / Endoscopic)
Advantages-No brain retraction
No additional risk of anosmia
Operation need not be delayed by brain swelling
Disadvantages-Localization of fistula must be very precise
Graft is placed extradurally and not tamponaded by the brain
Saturday, September 20, 2008
Extracranial open approaches
Trans-sphenoidal repair for CSF rhinorrhoea after pituitary surgery
Sublabial, transseptal or endonasal route Sphenoid mucosa is stripped and repair is performed with fascia lata & secured with fibrin glueSphenoid sinus packed with fat and glue ±autologous bone/ cartilage to reinforce the opening of sphenoid sinus
(Tamasauskas A et al. Management of cerebrospinal fluid leak after surgical removal of pituitary adenomas . Medicina (Kaunas). 2008;44(4):302-7 )
Saturday, September 20, 2008
Extracranial open approachesExternal ethmoidectomy-
Most common extracranial approach to fistulas of the cribriform and ethmoid regionsNaso-orbital (Lynch-howarth incision) midway between nasal dorsum and medial canthus along the curvature of nasofacial creaseEthmoidectomyTracer to identify the site of leakRepaired with fascia + glue + pedicled mucoperiosteal flap + supported by nasal packing
Transmastoid approach-For # petrous bone involving tegmen tympani with intact hearing
Saturday, September 20, 2008
Other extracranial techniques
Primary repair of facial fractures
(with sinus repair and ablation as necessary)
Frontal osteoplastic sinusotomy ( repair of posterior sinus wall or cranialization of sinus & packing - in case of simple fracture through posterior wall of frontal sinus without evidence of comminution of skull base or significant cerebral contusion )
Saturday, September 20, 2008
Transnasal Endoscopic repair
Clear anatomical exposure of the roof of the nasal and sinus cavities by the endoscope
Excellent field of vision, allowing exact localization of the leak
The ability to clean mucosa from the bony defect precisely.
Accurate position of the graft material over the defect.
Saturday, September 20, 2008
Transnasal Endoscopic repair
Variety of options for techniques to repair the defect of the anterior skull base, but the principle concept is still the same: "water-tight closure".
Mucoperiosteal flaps from various donor sites (especially the nasal septal) was rotated to the leak area to seal the defect, with a success rate of 95-100%
Saturday, September 20, 2008
Transnasal Endoscopic repairSmall sized defect( < 0.5 cm) -mucosal graft or flapLarger defect(> 0.5cm)- bone or cartilage graft. Septal cartilage is better as a free graft because of its property of pliability, which makes it easier to insert through the skull base defectThere is no limitation for endoscopic repair of sphenoid sinus fistula as regards to the size of the bony defectHowever, ethmoid roof defect > 1.5cm is considered a relative contraindication to endoscopic repair
Saturday, September 20, 2008
Transnasal Endoscopic repair-Sphenoid sinus
Procedure-Nasal cavities infiltrated with LAEndoscopic sphenoidotomy accomplished through transethmoid approachIdentify the defect, remove any residual mucosa as it prevents adhesion of the graftFascia lata with fat graft harvestedFascial graft placed over the defect + glue + fat graftReinforced with surgicel gelfoam + nasal pack
Saturday, September 20, 2008
Transnasal Endoscopic repair –Sphenoid sinus defect
Endoscopic approach to sphenoid sinusdefect
Saturday, September 20, 2008
Transnasal Endoscopic repair –Cribriform plate defect
Approach same as for transnasal endoscopic sphenoid sinus repairComplete ethmoidectomy performed to expose defects of anterior skull baseIdentify the defect, remove any residual mucosa as it prevents adhesion of the graftMucosal graft or a composite mucosa-turbinate graft harvested from opposite nasal cavityA free bone/turbinate graft may be placed on the intracranial side of the bony defect between dura & skull base ( Underlay) or can be placed directly over the defect ( Onlay) & secured with fibrin glue
Saturday, September 20, 2008
Transnasal Endoscopic repair
Success or failure depends uponSurgeon’s experienceCorrect localization of fistula pre and intraoperativelyRaised ICP
No statistical difference in results based onType of graft ( Free vs Pedicled, mucosa vs fascia, muscle vs fat)Underlay or onlay graftUse of lumbar drain post-operatively
( Zweig JL et al. Endoscopic repair of CSF leaks to the sinonasal tract: Predictors of success. Otolaryngol Head Neck Surg 123: 195-201, 2003.)
Saturday, September 20, 2008
Transnasal Endoscopic repair –Cribriform plate defect
Saturday, September 20, 2008
Transnasal Endoscopic repair
Saturday, September 20, 2008
Surgical approaches to skull base with inherently higher risk of developing post-operative CSF rhinorrhoea
Subfrontal approach with breach of frontal sinus
Anterior skull base lesion ( e.g. olfactory groove meningioma )
Transsphenoidal
Transtemporal or suboccipital approach to acoustic tumours
Saturday, September 20, 2008
Prevention of CSF leaks
Anterior cranial fossa-Management of frontal sinus
Subfrontal approaches
Middle cranial fossa-Trans-sphenoidal
Posterior cranial fossa-Suboccipital or transtemporal approach to acoustic neuroma
Saturday, September 20, 2008
Management of frontal sinus
Frontal sinus entered duringpterional/frontal craniotomy
Mucosa not violated Mucosa entered
•Removal of all remaining mucosa•Packing the sinus with
antiobiotic impregnated gelfoam•Covering defect with pericranial
graft sewn to dura
No further treatmentis required
Saturday, September 20, 2008
Subfrontal approachesAnterior skull base lesions such as meningioma or primary nasopharyngeal tumours may require resection of underlying dura or boneSmall defect-Packing with fat/muscle and covering with fascia+biological glueLarge defect- Extensive reconstruction with fascial graft + biological glue ± autologous bone graft / methylmethacrylate / tantalum mesh Elevate the periosteum as a separate flap at the start of procedure to create a periosteal flap layer for repair of skull base bony/dural defect
Saturday, September 20, 2008
Trans-sphenoidal Approach
Incidence of CSF leak-1.4 to 6.4%Arachnoid violation during trans-sphenoidal
procedures
Fascia lata graft of proper size to be placed intradurally against the diaphragma sellae
±Marlex mesh to reinforce fascial graft
Sphenoid sinus packed with fat and glue
•Valsalva manuever•Posterior nasal pack against the sphenoid sinus
•LP drain
Saturday, September 20, 2008
Acoustic Neuroma surgery
Incidence – 6-30 %
Translabyrinthine, Suboccipital, Transsigmoid approach
Well- pneumatized petrous bone may predispose to leakage during drilling of posterior wall of meatus
Mastoid air cellsMiddle ear and Eustachian
tube
CSF rhinorrhoea
Saturday, September 20, 2008
Acoustic Neuroma surgery
Violation of mastoid air cells- Seal with bone wax and packing with fat & muscle
Transmastoid approach for CSF leak localization
Free adipose tissue autograft in the bone defect
Careful closure of fascial, subcutaneous & skin layers
Saturday, September 20, 2008
Controversies in Management -Routine Antibiotic prophylaxis
Post –traumatic CSF leak following Basilar skull fracture
Prophylactic Antibiotics
FORPrevention of Meningitis
AGAINSTElimination of commensal flora
of nasopharynx with subsequent infection by more virulent
Gram neg.organisms
Saturday, September 20, 2008
Controversies in Management -Routine Antibiotic Prophylaxis
FOR AGAINST
Eljamel MS. Antibiotic prophylaxis in unrepaired CSF fistulae. Antibiotic prophylaxis in unrepaired CSF fistulae. Br J Neurosurg. 1993;7(5):501-5.
Risk of meningitis was 7.6% (8/106)in the treated and 11.9%(13/109) in the untreated group. • Statistically non- significant reduction• More cases of Gram-negative infection and of partially-treated meningitis in the treated group.
Brodie HA . Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae. A meta-analysis. Arch Otolaryngol Head Neck Surg. 1997 Jul;123(7):749-52
2.5%(6/237). who received prophylactic antibiotics developed meningitis compared to 10 % (9/87) who did not receive prophylactic antibiotics
Statistically significant reduction
Saturday, September 20, 2008
Controversies in Management -Routine Antibiotic Prophylaxis
Klastersky J, Sadeghi M, Brihaye J. Antimicrobial prophylaxis in patients with rhinorrhea or otorrhea: a double-
blind study. Surg Neurol. 1976 Aug;6(2):111-4.
A total of 52 patients was studied, 26 in each treatment group. Meningitis developed in one patient in the placebo group.
Statistically non-significant
CURRENT RECOMMENDATIONRoutine prophylactic antibiotics are no longer
recommended in Post-traumatic CSF leak
Saturday, September 20, 2008
Controversies in Management -CT Cisternography vs MR Cisternography
The sensitivity in detecting CSF fistulae with MR cisternography (CISS: 93.6 %) was higher than with CT cisternography (72.3 %). Although the localization of CSF fistulae always proved possible with MR cisternography, this could only be accomplished with CT in 70 % of cases.
(Eberhardt KE, Hollenbach HP, Deimling M, Tomandl BF, Huk WJ. MR cisternography: a new method for the diagnosis of
CSF fistulae. Eur Radiol. 1997;7(9):1485-91.)
Saturday, September 20, 2008
Controversies in Management -CT Cisternography vs MR Cisternography
The sensitivity and specificity of the MR method-T2*-weighted 3D-CISS sequence(88.9% and 95.1%) is higher compared with CT cisternography (77.8% and 87.8%). The MR method is superior to CT cisternography, is noninvasive, the administration of contrast agent is no longer necessary.
(Eberhardt KE et al. MR diagnosis of cerebrospinal fluid fistulas using a 3D-CISS sequence Rofo. 1997 Dec;167(6):605-11 )
Saturday, September 20, 2008
Controversies in Management -Open/ Endoscopic Repair
The conventional approaches for repairing to anterior skull basedefect are the extracranial route (naso-orbital incision) or craniotomy with pericranial flapThese approaches to repair the defect of the anterior skull basehave a variable success rate of 60 to 80 percentsThe morbidity associated with craniotomy such as a loss in the ability to smell and prolonged hospitalization has made the endoscopic approach an alternative option. In the series of endoscopic repair, the success rate was 85.7% after the initial procedure and 100% after a second one.
(Mattox DE, Kennedy DW. Endoscopic management of cerebrospinal fluid leaks and encephaloceles. Laryngoscope 1990;100:858-62. )
Saturday, September 20, 2008
Controversies in Management -Open/ Endoscopic Repair
The endoscopic approach should be considered as the preferred method if the skull base defect is endoscopically accessible.Endoscopy offers the advantage of reduced hospitalization and better visualizationCraniotomy approach is still the back-up procedure if the endoscopic one fails
Saturday, September 20, 2008
AIIMS Experience
Retrospective analysisStudy period - January 2001 to December 2006, spanning a period of 6 years. Total no. of patients – 204,
CSF rhinorrhoea – 179CSF otorrhoea – 25Patients with minor traumatic CSF leaks which ceased spontaneously within first 48 hours were excluded.
Saturday, September 20, 2008
AIIMS Experience
CSF Otorrhoea
Traumatic Post-operative
CSF Rhinorrhoea
Traumatic
Post-operative
Spontaneous
Saturday, September 20, 2008
AIIMS Experience
25
79
35
65
0
20
40
60
80
Num
ber o
f Pat
ient
s
Figure 1
25 79 35 65
Otorrhoea Traumatic Rhinorrhoea
Spontaneous Rhinorrhoea
Postop Rhinorrhoea
Saturday, September 20, 2008
AIIMS ExperienceTraumatic CSF Rhinorrhoea
Spontaneous CSF Rhinorrhoea
Post-opCSF Rhinorrhoea
CSF Otorrhoea
Total number of patients
79 35 65 25
Mean Age 26.3 Years 38.7 Years 36 Years 28.2 Years
Sex ratio (M:F)
6.1:1 0.52:1 0.9:1 2.1:1
Unilateral / Bilateral
62/17 28/7 20/45 25/0
Saturday, September 20, 2008
AIIMS Experience –Traumatic CSF rhinorrhoea
n=79
Maximum number of patients [33(41.77%)] presented immediately after trauma, followed by 9(11.3%) patients who presented within first two weeks following trauma.
11 (13.9%) patients had history of meningitis.
Saturday, September 20, 2008
AIIMS Experience –Traumatic CSF rhinorrhoea
2 5
55
15
20
10
20
30
40
50
60
Num
ber o
f Pat
ient
s
Radiological findings(Figure 8)n-79
2 5 55 15 2
Pneumocephalus
Mastoid # or Petrous
Temporal bone
Cribriform plate #
Frontal bone #/ ACF # Normal
Saturday, September 20, 2008
AIIMS Experience –Traumatic CSF rhinorrhoea
The patients were managed conservatively or surgically based upon the time of presentation, magnitude of leak, history of meningitis or history of recurrences. Five (31.2%) patients were treated with bed rest, acetazolamide, and frusmide alone, while 11(68.7%) patients were treated with additional lumbar CSF drain. Treatment modality( Figure 10)
n‐79
16 Conservative
63 Surgical
Saturday, September 20, 2008
AIIMS Experience –Traumatic CSF rhinorrhoea
Surgical Treatment ( Figure 11)n-63
2
28
10
112
10
Intradural repair
Extradural repair
Sandwich repair
Exteriorisation of Frontalsinus
Endoscopic repair
TransnasalTranssphenoidal packingof Sphenoid sinus
Saturday, September 20, 2008
AIIMS Experience –Traumatic CSF rhinorrhoea
Complications: 12 (15.1%) patients developed postop meningitis
Follow-up and outcome :
Mean follow up -11 m( 1 m-4 yrs)
65 (82.27%) - no further leaks,
6(7.59%) - recurrence of CSF leak
{HCP was associated, 2/6 required re-surgery}
1(1.26%) patient died of fulminant post operative meningitis
Saturday, September 20, 2008
AIIMS Experience –Spontaneous CSF rhinorrhoea
n=35
Mean age = 38.7 Years
M: F =0.52:1
13 (37%) patients presented with history of meningitis
Saturday, September 20, 2008
AIIMS Experience –Spontaneous CSF rhinorrhoea
24
5 42
0
5
10
15
20
25
Num
ber o
f pat
ient
s
Cribriform pla tedefect
Se lla r floor de fect Hydrocepha lus Norm a l
Radiological findings (Figure 19)n-35
Saturday, September 20, 2008
AIIMS Experience –Spontaneous CSF rhinorrhoea
3 patients managed conservatively, only 1 require LP drain
First leaks and patients not having history of recurrent meningitis, responded well to conservative measures alone.
Treatment Modality ( Figure 21)
urgical
3 Conservativ
32 S
e
Saturday, September 20, 2008
AIIMS Experience –Spontaneous CSF rhinorrhoea
Surgical Management(Figure 21)n-35
4 5 2
19
2
Intradural repair
Extradural repair
Endoscopic repair
Transnasal transsphenoidalsellar packing
VP shunt/ Ommaya/ TPshunt, other CSF diversionprocedures
Saturday, September 20, 2008
AIIMS Experience –Spontaneous CSF rhinorrhoea
Complications: 4(11.42%) patients developed postop meningitis Follow-up and outcome :
Mean follow up -9 m( 1 m-2.9 yrs) 29(82.85%) - no further leaks, 2(5.71 %) - recurrence of CSF leak{1/2 required surgery – TP shunt followed by
Extradural repair} 1(2.85%) patient died of fulminant post operative
meningitis
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
40
7
18
0
5
10
15
20
25
30
35
40
Num
ber o
f pat
ient
s
Pituitary Adenom a CP angle les ion Frontal les ions
Primary Disease (Figure 26)n-65
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
Primary Surgery(Figure 27)n-65
7
40
18
TNTS/ SLTS
Frontalcraniotomy
RMSOC/Mastoidectomy
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
Treatment modality (Figure 28)n‐65
31 Surgical
34 Conservative
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
Conservative Management (Figure 29)n-34
1024 Bed rest, Acetazolamide,
Frusemide
Lumbar CSF drain
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
Surgical Management (Figure30)n-31
20
9
2
0
5
10
15
20
25
Transnasal repair Frontal s inus exteriorisation Mastoid ce lls w axing w ithreexploration
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
Complications: Nine (13.8%) patients developed complications.
7(10.76%)-Postop meningitis, 2(3%)- Septicemia
Follow-up and outcome :
Mean follow up -10 m( 1 m-4.4 yrs)
46 (70.8%) - no further leaks,
9(13.8 %) - recurrence of CSF leak
4(6.1 %) patients died in post op. period
Saturday, September 20, 2008
AIIMS Experience –Post-operative CSF rhinorrhoea
2
3
1
3
1 1
0
0.5
1
1.5
2
2.5
3
Num
ber o
f Pat
ient
s
1st Recurence 2ndRecurrence
Management of Recurrence (Figure 32)
Intradural repair
Conservative
LP shunt
Conservative+Transnasalrepair
Saturday, September 20, 2008
CSF rhinorrhoea – The Way Ahead
Improved flexible endoscopy
Availability of biological glue
Newer non-invasive 3-D imaging techniques for fistula localization
Minimally invasive approach
Saturday, September 20, 2008
Take Home messageCSF rhinorrhoea- potentially life threatening owing to risk of meningitisMC cause- trauma with Basilar skull #, though post-operative leaks are also on the riseMC site – Cribriform plate of ethmoidDiagnosis by a variety of Clinical & radiological techniques, though MR cisternography with heavily T2W and 3D CISS sequences being the modality of choiceConservative and surgical management depending on the cause, site and duration of CSF leakVariety of Intracranial/ Extracranial , open/ endoscopic approaches availableFuture trend is towards minimally invasive endoscopic approaches
Saturday, September 20, 2008
Thank You